12/13/2013 Franois-Xavier Bagnoud Center Todays Webinar will be - - PDF document

▶
12 13 2013
SMART_READER_LITE
LIVE PREVIEW

12/13/2013 Franois-Xavier Bagnoud Center Todays Webinar will be - - PDF document

Aug 14, 2023 244 likes •452 views

12/13/2013 Franois-Xavier Bagnoud Center Todays Webinar will be starting soon For the audio portion of this meeting: Dial 1-888-394-8197 Enter participant code 733225 HIV-MHRC Supporting Engagement and Retention in Care Using the PCMH

slide-1
SLIDE 1

12/13/2013 1

HIV-MHRC

François-Xavier Bagnoud Center

Today’s Webinar will be starting soon

For the audio portion of this meeting: Dial 1-888-394-8197 Enter participant code 733225 Supporting Engagement and Retention in Care Using the PCMH Model: Best Practices from the California HIV/AIDS PCMH Demonstration Project

HIV-MHRC

François-Xavier Bagnoud Center

Guidelines for Our Online Meeting Room

  • PLEASE TURN OFF YOUR COMPUTER SPEAKERS
  • Kindly mute your phone line

– Dial in: 1-888-394-8197 – Enter participant code: 733225#

  • Questions & Interactive activities

– Enter questions into the chat room – Polls

  • Evaluation

3

slide-2
SLIDE 2

12/13/2013 2

HIV-MHRC

François-Xavier Bagnoud Center

Today’s Presenters:

Steve Bromer, MD

Medical Director of Practice Facilitation HIV Medical Homes Resource Center

Amy Sitapati, MD

Interim Medical Director, Owen Clinic Associate Clinical Professor of Medicine UC San Diego Health System

Kathleen Clanon, MD

Associate Chief Medical Officer Alameda Health System

4

Learning goals

Participants will:

  • Recognize how key concepts of the PCMH model support

sustainable improvement in the HIV Treatment and Care Cascade.

  • Employ effective strategies for population and panel

management to retain patients after empanelment.

  • Recognize specific challenges/solutions in engagement and

retention from the UCSD and HIV ACCESS (CHC) perspective.

  • Discuss the role of team-based care in supporting clients’

access to wraparound services.

  • Identify engagement and patient retention deliverables

specific to PCMH recognition.

Today’s Agenda

  • 1. PCMH Commercial
  • 2. Case Discussions
  • 3. Your Questions, Answered!
slide-3
SLIDE 3

12/13/2013 3

GARDNER CASCADE GOT YOU DOWN?!?!

100% 82% 66% 37% 33% 25% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

100% 82% 66% 37% 33% 25% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed 100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

Retention Imperative

  • Health of patients
  • HRSA/Ryan White

requirements

  • Future funding
  • Prevention of HIV

transmission

slide-4
SLIDE 4

12/13/2013 4

PCMH IS HERE TO HELP!!!

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

THE PCMH MODEL CAN HELP YOU IMPROVE PATIENT RETENTION

THE BUILDING BLOCKS OF THE PATIENT-CENTERED MEDICAL HOME ARE DESIGNED TO KEEP PATIENTS ENGAGED IN CARE

slide-5
SLIDE 5

12/13/2013 5

The Building Blocks can help us address the cascade!

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

Retention

Improved access (8) → Patients can be seen by care team when they need to be Empanelment (3)/team-based care (4)/population management (6) → Team takes responsibility for identifying out-of-care patients and facilitating outreach Care coordination (9) → Addressing patients’ other needs so they can focus on their health Patient-team partnership (5) /Continuity of care (7) → Fostering long-term relationships between patient and provider/team to build a sense of connection to care Data-driven improvement (2) → Using data to understand characteristics of

  • ut-of-care patients to identify opportunities for intervention

Prescription of ART

Empanelment (3) /team-based care (4) /population management (6) → Team is accountable for identifying patients not on ART Care coordination (9) → Addressing patients’ other needs so they can focus on their health Patient-team partnership (5) /Continuity of care (7) → Building trust between patient and provider/team and shared decision-making about treatment

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

slide-6
SLIDE 6

12/13/2013 6

Viral Load Suppression

Improved access (8) → Patients can be seen by care team when they need and have phone and/or electronic access to provider/team to avoid treatment interruptions Empanelment (3) /team-based care (4) /population management (6) → Team takes responsibility for identifying opportunities for outreach/intervention with patients at risk for poor outcomes Care coordination (9) → Addressing patients’ other needs so they can focus on their health Patient-team partnership (5) /Continuity of care (9) → Fostering long-term relationships between patient and provider/team and shared-decision-making Data-driven improvement (2) → Using data to understand characteristics of non- virally-suppressed patients to identify opportunities for intervention

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

Diagnosis and Linkage

Access to care (8) → New patients can be seen upon diagnosis; out-of-care patients can access appointments when they are ready to come back to care Engaged Leadership (1) / Empanelment (3)/team-based care (4)/population management (6) → Larger organization (hospital/health center) effectively manages patient population to promote HIV testing and linkage to care

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

THANKS FOR SAVING THE DAY, PCMH!!!

slide-7
SLIDE 7

12/13/2013 7

Another Benefit: Avoiding Quality Whack-a-Mole

address multiple quality indicators at once…

Poll Question

Which of the following describes your clinic’s current retention efforts?

  • Working very well, retention is >95%
  • Could be better, retention is 80-95%
  • Need help, retention is < 80%
  • We have a retention program, but I’m not sure how

well it’s working

  • We don’t have a retention program
  • Don’t bother me, I’m eating my lunch

UC San Diego Health System:

Our HIV/AIDS medical home: The Owen Clinic

Providing care for 3,100 HIV/AIDS lives

slide-8
SLIDE 8

12/13/2013 8

What is fundamentally different about the PCMH model of care delivery?

hspca.convio.net

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

Retention

Do you know your data? And have you addressed access, teams, population management, care coordination to improve the care delivery? What do you do proactively to prevent patients from falling out of care?

Do you know your RETENTION PERFORMANCE data?

Reported Baseline Actual 01/01/2013-10/31/2013 Scheduled Visits between now and Year end Scheduled Visits (Plus 20% no show rate) Predicted (actual + scheduled and 20% no show) Target Gap between Predicted visits and Target Numerator 2217 1911 262 210 2121 2286 165 Denominator 2823 2628 18 2646 2646 Percentage 78.53% 72.72% 80.14% 86.39% Targeted Goal (visit gap with 20% no show) 198 Medical Visits Milestone: Improve medical visit performance by 10% over baseline for the period 1/1/2013-12/31/2013 Metric: Number of HIV-infected clients who had a medical visit with a provider with prescribing privileges, i.e. MD, PA, NP, in an HIV care setting two or more times at least 3 months apart during the measurement year / Number of HIV-infected clients who had a medical visit with a provider with prescribing privileges at least once in the measurement year

Dynamic Reports run every 1-2 weeks Adjust strategy MONTHLY Do you only run reports on patients who have fallen Out of care , or do you run reports for patients at risk? Publish: Clinic wide with baseline and goal Team based report card Provider based report card

slide-9
SLIDE 9

12/13/2013 9

Have you adopted an OPEN ACCESS model of care delivery? Do you have EVENING and WEEKEND access for routine care delivery?

Are there opportunities for you to IMPROVE ACCESS?

washingtonpost.com gradschool.usciences.edu

WHO & HOW:

  • 1. Retention Weekly Meeting:

Retention Specialist, RN Panel Manager, Director, Nurse Manager, Case Manager

  • 2. Inpatient Care Transitions Weekly

Meeting: Transition of Care Nurse, Inpatient HIV Attending; Case Management; Inpatient and Ambulatory Pharmacists THE TOOLS:

  • 1. Tracking database
  • 2. Operational “live” database in the EHR
  • 3. Marry panel management activity and

case management

How do you use the REGISTRY and TEAM BASED care delivery to proactively prevent poor RETENTION?

Are you offering patient centered promotion of literacy and HEALTH INFORMATION and ACCESS?

Patient computer lab, English and Spanish Patient Portal Chart Access, English and Spanish Patient Centered Web Page

27

slide-10
SLIDE 10

12/13/2013 10

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

How can we be leveraging HIV POPULATION MANAGEMENT to improve other quality

  • utcomes?

Weekly, a team meets with its Multi-disciplinary components Sort HIGH VIRAL LOAD, and Aim to improve the TEAM VIRAL LOAD Live operational database with real-time action Goal: to improve TEAM HIV VIRAL LOAD

Poll Question

What approaches does your clinic use to improve patient engagement and retention? (Select all that apply) 1. Continuous quality improvement team with performance goal 2. Patient risk acuity 3. Provider loading (availability to accept new patients) 4. Evening and weekend hours 5. Open access (same/next day scheduling) 6. Patient web portal to health record 7. Bilingual/multilingual patient resources 8. Patient registry reports including retention 9. Retention specialist

  • Providing care since 1974
  • 3 Federally Qualified Health

Centers, Wellness Center and Day Labor outreach

  • Primary Care, Specialty

Services, Dental, Behavioral and Mental Health, HIV, Teen, Wellness, Outreach and Navigation Services

slide-11
SLIDE 11

12/13/2013 11

Who do we serve?

  • 13,000 adults and children
  • 3,300 under age 19
  • 2,300 over age 60
  • 49% Medi-Cal, Medicare,

CMSP, Healthy Families

  • 85% at/below 200% of

poverty level

  • 40% at/below poverty level
  • 36% uninsured
  • 54,685 visits (2012)
  • 350 patients living with HIV

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

The Building Blocks can help us address the cascade!

Engaged Leadership

  • At its core, all of health care is relational
  • Continuous, trusting, non-judgmental,

“first-name” relationship over time

  • “Every interaction creates opportunities

for empowering patients and staff to build healthy lives and communities.”

slide-12
SLIDE 12

12/13/2013 12

Does retention look like this? Or this? Control: Who really makes the decisions

Acuity

“Control”

The “System” Patient/Family

Low High 100

  • 1. Control – who makes the final decision influencing outcome?
  • 2. Influences – family, friends, co-workers, religion, values, money
  • 3. Real opportunity to influence health costs/outcomes – influence
  • n the choices made – behavioral change
  • 4. Current model – tests, diagnosis, treatment (meds or procedures)

Southcentral Foundation

slide-13
SLIDE 13

12/13/2013 13

Building Blocks of High-Performing Primary Care: Share-the-CareTM Model EMR and Data for Improvement Enhancing the Relationship

slide-14
SLIDE 14

12/13/2013 14

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

The Building Blocks can help us address the cascade!

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

The Building Blocks can help us address the cascade!

slide-15
SLIDE 15

12/13/2013 15

Anti-Stigma Campaign

slide-16
SLIDE 16

12/13/2013 16

100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed

WCHC retention and engagement cascade

72% 82% 80% 76%

slide-17
SLIDE 17

12/13/2013 17

NCQA and Retention in Care

  • PCMH Standard 2, Element D
  • Patients not recently seen by practice, patients on

specific medications

  • PCMH Standard 3, Element B
  • Establish criteria and systematic process to identify

high-risk patients

  • PCMH Standard 6, Element A, C, D and E
  • (A) Chronic care measure, (C) CQI goals, (D) show

improvement and (E) Report performance

DEBATE: Is it best to have a retention specialist

  • r to have it part of everyone’s job?

Should an HIV Primary Care Medical Home have a RETENTION SPECIALIST?

Out of care Advantages:

  • Knowledge of complex health
  • Navigation
  • Clear tracking in database
  • Follows complex algorithm
  • Coordinates patients

transitioning

  • Out, incarceration, panel

manager

  • Clear focused roles and

responsibilities

slide-18
SLIDE 18

12/13/2013 18

Should an HIV Primary Care Medical Home have a RETENTION SPECIALIST?

Disadvantages:

  • The “you’re it” phenomenon
  • Diversity of patients rewards

diversity of care givers working on problems – not just one

  • Staff turnover
  • Retention is too big a job for one

person

  • No more silos!

Poll: What is your opinion?

Is it better to have a identified retention specialist or integrate retention into everyone’s jobs?

  • Retention specialist
  • Integrate retention

into everyone’s jobs

54

Thoughts? Questions?

slide-19
SLIDE 19

12/13/2013 19

HIV-MHRC

François-Xavier Bagnoud Center

Thank you!!!

55 HIV-MHRC

François-Xavier Bagnoud Center

Please complete online

Webinar Evaluation

https://www.surveymonkey.com/s/EngagementandRetention

by Friday, December 27, 2013

56 HIV-MHRC

François-Xavier Bagnoud Center

57

slide-20
SLIDE 20

12/13/2013 20

HIV-MHRC

François-Xavier Bagnoud Center

Resource Repository

http://www.careacttarget.org/mhrc

58 HIV-MHRC

François-Xavier Bagnoud Center

Next HIV-MHRC Webinar: Early Spring 2014

59